Figure 6.

A 34-year-old female with a history of a left-sided tubal stump pregnancy, a year after undergoing laparoscopic tubal ligation. Following the failure in sterilization, tubal occlusion with Essure device was proposed to her. The procedure was described as difficult with poor visibility because of endometrial bleeding and debris. The right implant was deployed with eight trailing coils visible in the uterine cavity. On the left side, a first implant was placed with no trailing coils visible after deployment. The surgeon suspected distal placement and decided to place another insert that left six trailing coils after deployment. (a) Hysterosalpingogram performed before Essure placement, showing bilateral tubal patency in both tubal stumps (arrow). (b) Scout image showing two inserts on the left side of the pelvic cavity, one of them having a straight shape, and distal migration of the right insert (arrowhead) after detachment from its proximal marker (arrow). (c) Hysterosalpingogram showing tubal occlusion of the right side and tubal patency of the left side (arrow) despite a correctly placed insert. On the right side, the outer coil is not delineated by the dye in the tube and the important distance between the proximal marker and the rest of the insert suggests a fracture rather than a stretching. Tubal perforation with the second “left” implant was suspected because the second implant was projected outside the uterine cavity and did not follow the course of the fallopian tube that was delineated by the contrast agent (arrowhead). Tubal perforation was confirmed during laparoscopic surgery.